Anaesthesia Section
Pain Management Practices and Perceived
Barriers among the Health Professionals in
Different Hospitals of Nepal
INTRODUCTION
Pain is one of the most common symptoms of any illness. According to pain management guidelines, pain should be adequately assessed and managed by multimodal regime minimising side-effects of drugs [1]. Despite the availability of resources, protocol and advances in pain management, improvement in pain management practices is still lacking in developing countries. There are certain barriers that act as obstacle in adequate pain management. The barriers can be classified into three categories: patient, health care professionals and health care system [2-4].
There have been nationwide surveys in different countries on practice of pain management and attempt on identifying barriers to pain management among health professionals [5-8]. However, in Nepal, the present authors did not find enough studies that attempted to explore the pain as public health problem. This study intended to find out the pain management practices and the perceived barriers among health professionals of different hospitals of Nepal.
MATERIALS AND METHODS
This was a descriptive cross-sectional multi-centred study carried out in five different tertiary hospitals of Nepal located in four different provinces, out of which four were academic institutes namely Tribhuvan University Teaching Hospital, Manipal Teaching Hospital, Lumbini Medical College Teaching Hospital and BP Koirala Institute of Health Sciences. The fifth was Bhaktapur Cancer Hospital.
Ethical approval for the study was obtained from Government based Nepal Health Research Council (NHRC, Reg'no.5o9/2017J).
The study was also funded by NHRC and the contract period of one year was decided. The investigator had to complete the study and submit the report at the end of one year. Formal permission was also taken from the concerned authorities of the selected hospitals. The study included doctors and nurses working in the hospitals. For calculation of sample size, confidence interval was taken 95% and allowable error was 5%. Fifty percent proportion was assumed as there was no specific proportion of good practice in previous studies. Thus, total sample size calculated was 385.
Operation room, Intensive Care Unit, Medical and Surgical wards and Emergency room of these hospitals were selected. The list of doctors and nurses were obtained from the duty rosters. Then simple random sampling technique, through lottery method, was adopted to select the proportionate number of doctors and nurses from different hospitals.
Written informed consent was obtained from each of the participants before data collection. Pre-designed self administered questionnaire was used for the study. An enumerator was chosen from each hospital. They were provided orientation on the tool and the technique of data collection. The questionnaires were distributed to the respondents in person and the filled questionnaires were returned after 2 days.
Pre-designed self administered questionnaire was used to collect information on pain management practice and perceived barriers. The practice questionnaire consisted of close-ended questions and the barrier questionnaire was in the form of 5-point Likert scale. For each item, frequency of scales 1, 2 and 3 were combined as negative Bigen MAn ShAkyA1, SujAtA ShAkyA2, ninAdini ShreSthA3
Keywords:
Insufficient staff, Pain management training, Strict opioid regulationABSTRACT
Introduction: Despite the availability of resources and protocol, and advances in pain management, improvement in pain management practice is still lacking especially in developing countries like Nepal. Certain barriers act as obstacle to adequate pain management. The barriers can be classified into three categories: barrier related to patient, health care professionals and health care system. There are very few literature that focuses on pain as public health problem in Nepal. So there is need for such multicentre study in the country.
Aim: To assess the pain management practices of the health professionals in different hospitals of Nepal and to identify different types of perceived barriers which prevent adequate pain management of the patients.
Materials and Methods: A cross-sectional multi-centre study was conducted among 292 health professionals of five different hospitals of Nepal. Simple random sampling technique was used to select the participants from each hospital. Data collection was done by using structured self administered questionnaire. Descriptive and bi-variate analysis was done.
Results: Out of 292 participants (182 doctors, 102 nurses and 10 health assistants), only 56 (19.2%) had participated in pain management training. Only 39.7% always used pain scale for assessment of pain. The documentation of pain was also poor with only 22.3% always doing documentation. The documentation of pain assessment was better among nurses when compared with doctors (p<0.005). The pain scale was always used for reassessment by 33.2%. The main barriers to pain management as perceived by the participants were opioids being strictly regulated (75.7%), insufficient staff in the hospital (73.4%), lack of knowledge among patients about pain management (66.8%) and least priority for pain management by hospital (60.1%).
response, and 4 and 5 were combined as positive response. The practice related questions were prepared based on the study of Louri M et al., and Ferrante P et al., [5,7]. Some of the barrier questions were extracted from the study of Jho HJ et al., and Jeon YS [6,9]. Pretesting of the questionnaire was done among nurses and residents of Department of Anaesthesiology of Tribhuvan University Teaching Hospital. The reliability of the tool was assessed by calculating the Cronbach’s alpha (r), the value of which was 0.78. As per findings and feedback from pretesting, some questions were rewritten in simple format to make them more meaningful and comprehensible.
STATISTICAL ANALYSIS
Data were entered in Epidata version 3.1 and analysed by using SPSS version 16.0. Data was analysed by using descriptive (frequency, percent, mean and standard deviation) and inferential statistics (chi-square test) as per the nature of the variables. These were then presented in tables and figures with the use of Microsoft Word and Microsoft Excel 2007. Statistical significance was considered at p<0.05.
RESULTS
Although the calculated sample size was 385, due to incomplete questionnaires and non-response, the total samples taken were 292. Most of the participants were doctors (61.6%), followed by nurses (34.9%) and paramedics (3.4%). The mean age of the participants was 29.6±8.4 years. The participants with postgraduate qualification were 80 (27.4%). Majority (69.5%) had work experience of <5 years [Table/Fig-1]. Only 56 participants (19.2%) had received pain management training in the past.
More than half of the participants (53.8%) always did assessment of pain on their patients. Documentation of pain was poor, with only 22.3% always doing documentation. Pain re-assessment was always done by most of the participants (67.8%). The side-effects of pain medication were assessed by only 45.2% [Table/Fig-2].
demographic characteristics number (n) Percent (%)
Age group (in years)
<30 172 58.9
≥30 120 41.1
gender
Male 129 44.2
Female 163 55.8
group of participants
Doctors 180 61.6
Nurses 102 34.9
Paramedics 10 3.4
Work experience (in years)
<5 203 69.5
≥5 89 30.5
educational qualification
Bachelor of Medicine and Surgery (MBBS) 100 34.2
Bachelor in Nursing (BN) 29 9.9
Certificate level in Nursing (PCL) 73 25.0
Doctor of Medicine (MD) 80 27.4
Health Assistant (HA) 10 3.4
Wards
Operation room 113 38.7
Medical and surgical ward 115 39.4
Intensive care unit 51 17.4
Emergency room 13 4.5
[Table/Fig-1]: Demographic Profile (n=292).
doctors nurses Paramedics total
n % n % n % n %
Frequency of pain assessment
Never 5 2.8 5 4.9 1 10 11 3.8
Sometimes 83 46.1 36 35.3 5 50 124 42.5
Always 92 51.1 61 59.8 4 40 157 53.8
documentation of pain assessment
Never 38 21.1 16 15.7 2 20.0 56 19.2
Sometimes 115 63.9 54 52.9 2 20.0 171 58.6
Always 27 15.0 32 31.4 6 60.0 65 22.3
reassessment after pain medication
Never 9 5.0 3 2.9 2 20.0 14 4.8
Sometimes 57 31.7 21 20.6 2 20.0 80 27.4
Always 114 63.3 78 76.5 6 60.0 198 67.8
Assessment of side-effects of medication
Never 12 6.7 4 3.9 1 10.0 17 5.8
Sometimes 91 50.6 47 46.1 5 50.0 143 49
Always 77 42.8 51 50.0 4 40.0 132 45.2
[Table/Fig-2]: Pain assessment.
Only 39.7 % always used pain scale for assessment of pain. The frequently used Pain scale was Visual Analog Scale (VAS) (42%). Despite pain re-assessment always been done by most of the participants, only 33.2% always used standard tools for pain reassessment [Table/Fig-3].
Physicians nurses Paramedics total
n % n % % % n %
Pain scale used for pain assessment
Never 24 13.3 22 21.6 6 60.0 52 17.8
Sometimes 86 47.8 36 35.3 2 20.0 124 42.5
Always 70 38.9 44 43.1 2 20.0 116 39.7
Pain scale used (n=215)*
Visual Analog Scale (VAS) 69 47.9 15 22.1 0 0 84 42
Numerical Rating Scale
(NRS) 62 43.1 5 7.3 1 10.0 68 34
Facial Pain Scale (FPS) 13 9.0 48 70.6 2 20.0 63 31.5
Pain scale used for reassessment (n=292)
Never 32 17.8 14 13.7 2 20.0 48 16.4
Sometimes 96 53.3 47 46.1 4 40.0 147 50.3
Always 52 28.9 41 40.2 4 40.0 97 33.2
[Table/Fig-3]: Use of pain scale.
*out of 240, only 215 participants answered about the specific pain scale that they use
The main barriers to pain management as perceived by the participants were opioids being strictly regulated (75.7%), insufficient staff in the hospital (73.4%), lack of knowledge among patients about pain management (66.8%) and least priority for pain management by hospital (60.1%) [Table/Fig-4].
While comparing the pain management practice between physicians and nurses, no significant difference was found in the practices, except in documentation of pain assessment, in which significantly more nurses were found to be documenting pain than the physicians (p<0.05) [Table/Fig-5].
Physicians nurses Paramedics total
n % n % n % n %
Reluctance of patient to
report pain 58 32.2 51 50 4 40.0 113 39.5
Patient does not like
pain medication 25 13.9 13 12.7 2 20.0 40 14
Patient cannot pay for
medication 32 17.8 18 17.6 1 10.0 51 17.8
No knowledge of
patient 128 71.1 57 55.9 6 60.0 191 66.8
Lack of communication
between patient and staff 95 52.8 33 32.4 2 20.0 130 45.5
No proper assessment
by staff 92 51.1 28 27.5 3 30.0 123 43
Inadequate knowledge
among staff 104 57.8 28 27.5 5 50.0 137 47.9
Lack of experience 118 65.6 40 39.2 5 50.0 163 57
Lack of time 91 50.6 30 29.4 3 30.0 124 43.3
Hesitation to prescribe
opioids 89 49.4 35 34.3 4 40.0 128 44.8
Reluctance of nurse 89 49.4 44 43.1 1 10.0 134 46.9
Lack of communication
of doctors and nurses 66 36.7 24 23.5 2 20.0 92 32.2
Opioids are strictly
regulated 127 70.6 82 80.4 7 70.0 216 75.5
Insufficient staffing 131 72.8 70 68.6 9 90.0 210 73.4
Lack of medication in
hospital pharmacy 93 51.7 34 33.3 5 50.0 132 46.2
Least priority by
hospital 117 65 51 50 4 40.0 172 60.1
[Table/Fig-4]: Perceived barriers. (n=292)
Pain management practice
Physician (n=180) nurses (n=102)
p-value*
number Percent number Percent
Pain training received
Yes 34 18.9 19 18.6
0.957
No 146 81.1 83 81.4
Frequency of using pain scale for assessment
Never 24 13.3 22 21.6
0.069
Sometimes 86 47.8 36 35.3
Always 70 38.9 44 43.1
Frequency of documentation of assessment
Never 38 21.1 16 15.7
0.005**
Sometimes 115 63.9 54 52.9
Always 27 15.0 32 31.4
reassessment after medication
Never 9 5.0 3 2.9
0.075
Sometimes 57 31.7 21 20.6
Always 114 63.3 78 76.5
Frequency of using pain scale for reassessment
Never 32 17.8 14 13.7
0.145
Sometimes 96 53.3 47 46.1
Always 52 28.9 41 40.2
Frequency of assessing side-effects of pain medication
Never 12 6.7 4 3.9
0.391
Sometimes 91 50.6 47 46.1
Always 77 42.8 51 50.0
[Table/Fig-5]: Comparison of pain management practice between physicians and nurses (n=282).
*chi-square test; **p significant at 0.05
Perceived barriers Physician nurse p-value*
number Percent number Percent
Reluctance of patient
to report pain 58 32.2 51 50.0 0.002**
Patient does not like
pain medication 25 13.9 13 12.7 0.470
Patient cannot pay for
medication 32 17.8 18 17.6 0.557
No knowledge of
patient 128 71.1 57 55.9 0.007**
Lack of communication between patient and
staff 95 52.8 33 32.4 0.001**
No proper assessment
by staff 92 51.1 28 27.5 <0.01**
Inadequate knowledge
among staff 104 57.8 28 27.8 <0.01**
Lack of experience 118 65.6 40 39.2 <0.01**
Lack of time 91 50.6 30 29.4 <0.01**
Hesitation to prescribe
opioids 89 49.4 35 34.3 0.009**
Reluctance of nurse 89 49.4 44 43.1 0.185
Lack of communication
of doctors and nurses 66 36.7 24 23.5 0.015**
Opioids are strictly
regulated 127 70.6 82 80.4 0.046**
Insufficient staffing 131 72.8 70 68.6 0.272
Lack of medication in
hospital pharmacy 93 51.7 34 33.3 0.002**
Least priority by
hospital 117 65.0 51 50.0 0.010**
[Table/Fig-6]: Perceived barriers to pain management among physicians and nurses. (n=282)
*chi-square test; **’p’ significant at 0.05
DISCUSSION
This multi-centre study, done among health professionals, has shown the current scenario of pain management practices in the tertiary level hospitals of Nepal. It also highlights the barriers to pain management. For effective pain management, the pain must be assessed using standard pain measurement tools and later re-assessed to test the adequacy of pain relief treatments. Documentation of pain scores is vital to know the dynamics of pain scores and adequacy of treatments. In this study, about half of the participants (53.8%) always asked about pain. However, only (39.7%) participants always used pain scale for assessment of pain. The frequently used Pain scale was VAS (42%). The documentation of pain was also poor with only 22.3% always documenting pain. Despite many participants (67.8%) claiming that the reassessment of pain was always done; only 33.2% used pain scale for reassessment. The side-effects of pain medication were always assessed by only 45.2%. The inadequate assessment of pain and poor documentation was also found in study done in mainland China by Ying GT et al., [8]. The importance of standardised pain scale was shown in study by Zoega S et al., where use of pain scale was associated with better pain management [10].
39% and pain scale was used in only 19%. In their study also, it was found that nurses were 2.2 times more likely to document pain than physicians.
The present authors also compared pain management practices among different hospitals of Nepal. The pain management practices were almost similar among all hospitals.
Overall the pain assessment and reassessment by using Standard pain assessment tools was only practised by few health professionals. The barriers that prevent adequate pain management are divided into 3 groups; barriers related to patient, related to health professionals and related to health care system. In this study, the barriers related to health care system as rated by the participants were opioids being strictly regulated (75.7%), insufficient staff in the hospital (73.4%) and least priority for pain management by hospital (60.1%). Among the barriers related to patient, lack of knowledge of patient about pain management was rated high (66.8%) by the participants. The barriers related to health professionals were not rated high as compared to previous two barriers and lack of experience of pain management (57%) was scored highest among the barrier related to health professionals.
The comparison of perceived barriers among the physicians and nurses showed difference in their perception regarding the barriers in many areas. Both doctors and nurses were consistent that insufficient staffing is one of the most important barriers preventing effective application of pain management. The results are compared with similar studies done in Morocco and South Korea [6,7]. The study done by Jho HJ et al., showed that barrier related to health professionals like time constraints was rated highest 75.8% by physicians and 66.1% by nurses [6]. The insufficient knowledge of pain control was next common perceived barrier, 60.5% by physician and 57.7% by nurses. In a study done in Morocco by Louri M et al., also, barriers related to health professionals was rated higher which are as follows [5]; inadequate pain assessment by staff 80%, inadequate experience of pain management 78%, insufficient knowledge of pain management 80% and lack of time 70%. Among the barriers related to health care system, the highest score was given to strict regulation of opioids 71%. In the present study, the surprising part is the health professional related barrier is not rated higher. The present authors were expecting the results similar to developing country like Morocco. In fact, poor knowledge of the health professionals on pain management has been identified in many studies [12-15]. The health care related barrier was rated higher in our study where most of the staff think that poor health care system is the main barrier for adequate pain management. The barrier related to health care system is also one of the important barriers that prevent effective pain management. Inadequate nursing staff leading to high workload prevented the pain management in study done in Saudi Arabia by Mohammed A et al., [16]. The consequences of high workload causes failure to deliver pain medication in time and as per demand, improper pain assessment and documentation. This eventually leads to dissatisfaction among nurses [16]. Another study was done among the nurses of Indonesia by Mediani HS et al., about perceived barriers to pain management [17]. The main barriers identified were inadequate nurse patient ratio (inadequate staffing), lack of education and training, lack of hospital support, lack of professional autonomy. Lack of professional autonomy was the one of the findings that ought to be mentioned. In developing countries, the nurses are not authorised to give medication on their own. They have to get permission from the physicians. The nurses in their interview mentioned that even they wanted to manage pain the lack of autonomy prevented to do so.
Strict regulation of opioids is the most frequent perceived barrier that is observed in our study. Opioids have addiction potential so manufacture and distribution of such drugs must be scheduled. Too much strict regulation will lead to formulary restriction, prescription barrier and dispensing barrier and result in unnecessary suffering to
those who really need. The Eastern Europe had suffered from such strict regulation of opioid [18]. There exist the guidelines published by World Health organisation which adopt the principle of Balanced Policy for safer management of controlled drugs [19].Countries can take more practical measure for prevention and control while ensuring patient access.
The comparison was also done among the different hospitals of Nepal. There was no major deviation of data from cumulative data. The health system related barrier was rated higher in each hospital. Due to the existence of the barriers, the overall pain management practice might not be up to the standard. The knowledge on pain management assessed by using standard tool, Nurses Knowledge and Attitudes Survey Regarding Pain (NKASRP), among nurses in one of the tertiary level hospitals was poor as shown by previous study in Nepal by Shakya B and Shakya S, [15]. As there is lack of multicentred data we can only assume that this is also true for rest of hospitals of Nepal. The authors did not find any other studies done in Nepal that attempt to find out barriers to pain management. The improvement in the pain management can be done by educational programs. The improvement in knowledge and change in behaviour of health personnels, like improvement in quality of pain assessment, use of pain scale and habit of documentation have been achieved by implementation of Pain Education Program (PEP) in China [20]. The “Essential Pain Management Workshop”, a one day workshop which is recognised worldwide to provide basic knowledge of pain management among the health professionals has been running successfully in developing countries including Nepal [21]. However, patient related barriers cannot be ignored and awareness has to be created among the patient about the pain management. And lastly, the authorities involved in health system management have to be made aware of the existing condition regarding pain management in Nepal.
Limitation(s)
The results may not reflect the pain practices of all the health professionals of Nepal. The pain assessment and documentation were measured using questionnaire. In order to measure the pain practices accurately the additional monitoring system like auditing is necessary. For obvious reasons, this was not done. The study assessed the perceived barriers of health professionals and may not represent actual barriers.
CONCLUSION(S)
The pain management services have to be developed as necessary health services in Nepal. The major barriers for developing effective pain management service in Nepal as shown by this study are strictly regulated medications, inadequate hospital staffing and poor awareness among patients. The first step in solving the problem is to identify the problem and accept it. There exists barriers at all the three levels and they should be addressed. The health professional related barrier can be overcome by providing adequate trainings on pain management to all health professionals. The medical societies in coordination with authorities of the government should develop policy for improvement of pain management and device action plans to implement in practice.
declaration: The study was also funded by NHRC and the contract period of one year was decided.
REFERENCES
Anaesthesiology ASo. Practice guidelines for acute pain management in the
[1]
perioperative setting. Anaesthesiology. 2012;116(2):248-73. Available from: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933589. Egan M, Cornally N. Identifying barriers to pain management in long-term care.
[2]
Nursing Older People. 2013;25(7):25-30. Available from: https://journals.rcni. com/doi/abs/10.7748/nop2013.09.25.7.25.e455.
Sun VC, Borneman T, Ferrell B, Piper B, Koczywas M, Choi K. Overcoming
[3]
International Associations for the Study of Pain. Barriers to Cancer Pain
[4]
treatment; cancer pain factsheet. 2008. Available from: https://www.iasp-pain. org/advocacy/content.aspxitemnumber=1106.
Louriz M, Belayachi J, Madani N, Abidi K, Dendane T, Belabes Benchekroun
[5]
A, et al. Practices and perceived barriers regarding pain management among emergency department physicians: a nationwide multicentre survey in moroccan hospitals. Acute Medicine and Surgery. 2016;3:360-63. Available from: https:// onlinelibrary.wiley.com/doi/epdf/10.1002/ams2.201.
Jho HJ, Kim Y, Kong KA, Kim DH, Choi JY, Nam EJ, et al. Knowledge, practices
[6]
and perceived barriers regarding cancer pain management among physicians and nurses in Korea: A nationwide multicentre survey. Plos One. 2014;9(8):01-07. Available from: https://journals.plos.org/plosone/article/file?id=10.1371/ journal.pone.0105900&type=printable.
Ferrante P, Cuttini M, Zangardi T, Tomasello C, Messi G, Pirozzi N, et al. Pain
[7]
management policies and practices in paediatric emergency care: a nationwide survey of Italian hospitals. BMC Paediatrics. 2013;13:01-09. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3848619/pdf/1471-2431-13-139.pdf. Ying GT, Konstantatos AH, Cai Fang Z, Ying HJ, Ai Fen Y, Boyd D. A cross
[8]
sectional exploratory survey of knowledge, attitudes and daily self reported pain assessment practice among nurses in mainland China. Pain Med. 2013;14(10):1468-76. Available from: https://academic.oup.com/painmedicine/ article/14/10/1468/1833071.
Jeon YS, Kim HK, Cleeland CS, Wang XS. Clinicians’ practice and attitudes
[9]
towards cancer pain management in Korea. Support Care Cancer. 2007;15:463-69. Available from: https://link.springer.com/article/10.1007/s00520-006-0183-x. Zoega S, Ward SE, Sigurdsson GH, Sveinsdottir H, Gunnarsdottir S. Quality
[10]
pain management practices in a University Hospital. Pain Management Nursing. 2015;6(3):198-210. Available from: https://www.painmanagementnursing.org/ article/S1524-9042(14)00106-4/pdf.
Eder SC, Solan EP, Todd K. Documentation of ED patient pain by Nurses and
[11]
Physicians. American Journal of Emergency Medicine. 2003;21(4):253-57. Available from: https://www.ajemjournal.com/article/S0735-6757(03)00041-X/pdf. Khalid WA, Alamari MS. Knowledge, attitudes and practices of health care
[12]
providers in Almadinah Almunawwarah, Saudi Arabia. Neurosciences. 2015;20(2):131-36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4727624/pdf/Neurosciences-20-131.pdf.
Tarzian AJ, Hoffmann DE. Barriers to managing pain in the nursing home: findings
[13]
from a statewide survey. J Am Med Dir Assoc. 2005;6:S13-19. Available from: https://www.jamda.com/article/S1525-8610(05)00220-3/pdf.
Lui LY, So WK, Fong DY. Knowledge and attitudes regarding pain management
[14]
among nurses in hongkong medical units. Journal of Clinical Nursing. 2008;17(15):2014-21. Available from: https://onlinelibrary.wiley.com/doi/ pdf/10.1111/j.1365-2702.2007.02183.x.
Shakya B, Shakya S. Knowledge and attitude of nurses on pain management in a
[15]
tertiary hospital of Nepal. International Journal of Nursing Research and Practice. 2016;3(1):03-08. Available from: http://www.uphtr.com/IJNRP/article/327. Mohammed A, Jones LK, Holroyd E. Organisational barriers to effective pain
[16]
management amongst oncology nurses in saudi Arabia. Journal of Hospital Administration. 2016;5(1):81-89. Available from: https://ecommons.aku.edu/ eastafrica_fhs_sonam/138/.
Mediani HS, Duggan R, Chapman R, Hutton A, Shields L. An exploration of
[17]
Indonesian nurses perceptions of barriers to paediatric pain management. Journal of Child Health Care. 2017;21(3):273-82. Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC5582643/pdf/10.1177_1367493517715146.pdf. Cherny NI, Catane R, Kosmidis PA. Problems of opioid availability and
[18]
accessibility across Europe: ESMO tackles the regulatory causes of intolerance and nedless suffering. Annals of Oncology. 2006;17(6):885-87. Available from: https://academic.oup.com/annonc/article/17/6/885/197140.
World Health Organization. Ensuring balance in national policies on controlled
[19]
substances: Guidance for availability and accessibility of controlled medicines 2011. Available from: http://www.who.int/medicines/areas/quality_safety/ GLs_ Ens_Balance_NOCP_Col_EN_sanend.pdf.
Zhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J. effects of pain
[20]
education program on nurses pain knowledge, attitudes and pain assessment practices in China. Journal of Pain and Symptom Management. 2008;36(6):616-27. Available from: https://www.jpsmjournal.com/article/ S0885-3924(08)00253-4/pdf.
Goucke CR, Jackson T, Morriss W, Royle J. Essential pain management: an
[21]
educational program for health care workers. World J Sur. 2015;39(4):865-70. Available form: https://link.springer.com/article/10.1007/s00268-014-2635-7/pdf.
PArtiCuLArS OF COntriButOrS:
1. Lecturer, Department of Anaesthesiology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. 2. Lecturer, Central Department of Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. 3. Lecturer, Department of Anaesthesiology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
PLAgiAriSM CheCking MethOdS: [Jain H et al.]
• Plagiarism X-checker: Sep 26, 2019 • Manual Googling: Nov 25, 2019 • iThenticate Software: Dec 23, 2019 (11%)
etyMOLOgy: Author Origin
nAMe, AddreSS, e-MAiL id OF the COrreSPOnding AuthOr:
Dr. Ninadini Shrestha,
EPC NO: 1789 GPO: 8975 977-9803517471, Kathmandu, Nepal. E-mail: [email protected]
Date of Submission: Sep 26, 2019
Date of Peer Review: Oct 16, 2019
Date of Acceptance: nov 28, 2019
Date of Publishing: jan 01, 2020
AuthOr deCLArAtiOn:
• Financial or Other Competing Interests: As declared above • Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
